Appeals Specialist

Required skills:

• 2 years' experience in Appeals Management
• Ability to handle appeals/grievances in health insurance industry
• GuidingCare experience - Must Have (Non Negotiable)
• Investigating and closing Cases

Additional Skills:

• Must have previous experience with Appeals and Grievances, experience working in Guiding Care, attention to detail, ability to work independently with little to no direct supervision, and willingness to help others

Purpose:

• The Appeals Specialist II will be responsible for the initial intake, analysis of appeals/grievances correspondence, and determination of next steps, with minimal supervision for Government Program lines of business. Responsible for collecting, organizing and tracking information to facilitate and expedite processing of appeals and grievances received from a variety of sources. Responsible for more complicated, high level research of cases, and other special projects as well as serving as a subject matter expert.

Essential Functions:

• 50% Independently researches contractual benefits, limitations & exclusions and claims to assist medical professional staff in performing the review of appeals, grievances, and reconsiderations. Prioritize, research, analyze, and perform accurate data entry for more complex appeals and grievances including high profile and escalated cases timely or expeditiously. Performs other duties such as file coordination activities including, but not limited to filing of all active files, purging of files for transport to off-site storage.
• 25% Utilizes professional written and verbal communications to assist in responses of all appeals and reconsiderations based on State and Federal requirements for all lines of business. Coordinates and completes vendor auditing duties, as needed. Reviews, researches problematic correspondence and works on special projects with Appeals Nurse or Management.
• 25% Interacts regularly with and responds to internal and external stakeholders, without breaching confidentiality of medical information. Actively participates in monthly meetings and discussions regarding quality appeal research, data entry and to problem solve any issues regarding the appeal intake/entry process.

Supervisory Responsibility:

• Provides resolution to problems that are readily identifiable with limited scope and are resolved in accordance with standard practices, procedures, applications or routines. Problem/Task resolution timeframe: The majority of tasks typically take one to two days to resolve.
• Under general supervision, proceeds alone or regular duties, referring questionable cases to supervisor.
• Failure to accomplish results can normally be overcome without significant effect on the organization
• Contacts are primarily within the department or function with occasional cross-functional ?interfaces. Some limited external customer contact on routine matters.

Qualifications

• To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required.
• Education Level: High School Diploma or GED
• Experience: 5 years' experience in settings such as managed care, health care or insurance payor environment & 2 years' experience in Appeals Management
• Preferred Qualifications: College Degree

Knowledge, Skills and Abilities (KSAs)

• Research and Problem Solving Skills.
• Ability to lead, train, coach and mentor less experienced team members.
• Ability to work both independently and as a member of a team with minimal supervision.
• Excellent organizational and analytical skills.
• Knowledge and understanding of medical terminology.

All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, protected veterans or individuals with disabilities.